Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 48
CPT code lookup
Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.
Prior authorization codes
| Code | Description | Source |
|---|---|---|
| A4543 | Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month | New Hampshire Precertification List, Pg 207 Original policy |
| A4544 | Electrode for external lower extremity nerve stimulator for restless legs syndrome | New Hampshire Precertification List, Pg 207 Original policy |
| A4545 | Supplies and accessories for external tibial nerve stimulator (e.g., socks, gel pads, electrodes, etc.), needed for one month | New Hampshire Precertification List, Pg 207 Original policy |
| A4575 | Topical hyperbaric oxygen chamber, disposable | New Hampshire Precertification List, Pg 207 Original policy |
| A4596 | Cranial electrotherapy stimulation (CES) system supplies and accessories, per month | New Hampshire Precertification List, Pg 207 Original policy |
| A4600 | Sleeve for intermittent limb compression device, replacement only, each | New Hampshire Precertification List, Pg 208 Original policy |
| A4604 | Tubing with integrated heating element for use with positive airway pressure device | New Hampshire Precertification List, Pg 208 Original policy |
| A7021 | Supplies and accessories for lung expansion airway clearance, continuous high frequency oscillation, and nebulization device (e.g., handset, nebulizer kit, biofilter) | New Hampshire Precertification List, Pg 208 Original policy |
| A7027 | Combination oral/nasal mask, used with continuous positive airway pressure device, each | New Hampshire Precertification List, Pg 208 Original policy |
| A7028 | Oral cushion for combination oral/nasal mask, replacement only, each | New Hampshire Precertification List, Pg 208 Original policy |
| A7029 | Nasal pillows for combination oral/nasal mask, replacement only, pair | New Hampshire Precertification List, Pg 208 Original policy |
| A7030 | Full face mask used with positive airway pressure device, each | New Hampshire Precertification List, Pg 208 Original policy |
| A7031 | Face mask interface, replacement for full face mask, each | New Hampshire Precertification List, Pg 208 Original policy |
| A7032 | Cushion for use on nasal mask interface, replacement only, each | New Hampshire Precertification List, Pg 208 Original policy |
| A7033 | Pillow for use on nasal cannula type interface, replacement only, pair | New Hampshire Precertification List, Pg 208 Original policy |
| A7034 | Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap | New Hampshire Precertification List, Pg 208 Original policy |
| A7035 | Headgear used with positive airway pressure device | New Hampshire Precertification List, Pg 208 Original policy |
| A7036 | Chinstrap used with positive airway pressure device | New Hampshire Precertification List, Pg 208 Original policy |
| A7037 | Tubing used with positive airway pressure device | New Hampshire Precertification List, Pg 208 Original policy |
| A7038 | Filter, disposable, used with positive airway pressure device | New Hampshire Precertification List, Pg 208 Original policy |
| A7039 | Filter, nondisposable, used with positive airway pressure device | New Hampshire Precertification List, Pg 208 Original policy |
| A7044 | Oral interface used with positive airway pressure device, each | New Hampshire Precertification List, Pg 208 Original policy |
| A7045 | Exhalation port with or without swivel used with accessories for positive airway devices, replacement only | New Hampshire Precertification List, Pg 208 Original policy |
| A7046 | Water chamber for humidifier, used with positive airway pressure device, replacement, each | New Hampshire Precertification List, Pg 208 Original policy |
| A9268 | Programmer for transient, orally ingested capsule | New Hampshire Precertification List, Pg 208 Original policy |
| A9269 | Programmable, transient, orally ingested capsule, for use with external programmer, per month | New Hampshire Precertification List, Pg 208 Original policy |
| A9292 | Prescription digital visual therapy, software-only, FDA cleared, per course of treatment | New Hampshire Precertification List, Pg 208 Original policy |
| A9513 | Lutetium Lu 177, dotatate, therapeutic, 1 mCi | New Hampshire Precertification List, Pg 209 Original policy |
| A9543 | Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 mCi | New Hampshire Precertification List, Pg 209 Original policy |
| A9582 | Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 mCi | New Hampshire Precertification List, Pg 209 Original policy |
| A9606 | Radium RA-223 dichloride, therapeutic, per UCI | New Hampshire Precertification List, Pg 209 Original policy |
| A9607 | Lutetium Lu 177 vipivotide tetraxetan, therapeutic, 1 mCi | New Hampshire Precertification List, Pg 209 Original policy |
| A9616 | Gallium Ga-68 gozetotide (Gozellix), diagn | New Hampshire Precertification List, Pg 209 Original policy |
| B4164 | Parenteral nutrition solution: carbohydrates (dextrose), 50% or less (500 ml = 1 unit), home mix | New Hampshire Precertification List, Pg 209 Original policy |
| B4168 | Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) - home mix | New Hampshire Precertification List, Pg 209 Original policy |
| B4172 | Parenteral nutrition solution; amino acid, 5.5% through 7%, (500 ml = 1 unit) - home mix | New Hampshire Precertification List, Pg 209 Original policy |
| B4176 | Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1 unit) - home mix | New Hampshire Precertification List, Pg 209 Original policy |
| B4178 | Parenteral nutrition solution: amino acid, greater than 8.5% (500 ml = 1 unit) - home mix | New Hampshire Precertification List, Pg 209 Original policy |
| B4180 | Parenteral nutrition solution: carbohydrates (dextrose), greater than 50% (500 ml = 1 unit), home mix | New Hampshire Precertification List, Pg 209 Original policy |
| B4185 | Parenteral nutrition solution, not otherwise specified, 10 g lipids | New Hampshire Precertification List, Pg 209 Original policy |
| B4187 | Omegaven, 10 g lipids | New Hampshire Precertification List, Pg 209 Original policy |
| B4189 | Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 g of protein, premix | New Hampshire Precertification List, Pg 209 Original policy |
| B4193 | Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 g of protein, premix | New Hampshire Precertification List, Pg 209 Original policy |
| B4197 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 g of protein - premix | New Hampshire Precertification List, Pg 209 Original policy |
| B4199 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 g of protein - premix | New Hampshire Precertification List, Pg 210 Original policy |
| B4216 | Parenteral nutrition; additives (vitamins, trace elements, Heparin, electrolytes), home mix, per day | New Hampshire Precertification List, Pg 210 Original policy |
| B4220 | Parenteral nutrition supply kit; premix, per day | New Hampshire Precertification List, Pg 210 Original policy |
| B4222 | Parenteral nutrition supply kit; home mix, per day | New Hampshire Precertification List, Pg 210 Original policy |
| B4224 | Parenteral nutrition administration kit, per day | New Hampshire Precertification List, Pg 210 Original policy |
| B5000 | Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - Amirosyn RF, NephrAmine, RenAmine - premix | New Hampshire Precertification List, Pg 210 Original policy |